Trauma Nursing Process: A Concise Guide

Trauma Nursing Process - TNP - TNCC 9th Ed What should you ask yourself after completing all of your interventions and reassessments? Does this patient need to be transferred to another hospital, to surgery, or to critical care? What happens prior to patient arrival? 1-3 1. Activate trauma team 2. Prepare trauma room 3. Don PPE 4. Assess for obvious uncontrolled external hemorrhage or unresponsiveness/apnea and the need to reprioritize to C-ABC 5**. Assess level of consciousness using AVPU 6. Open the airway 7**. Assess the patency and protection of the airway 8**. Assess breathing effectiveness What happens following patient arrival but before a decision to intubate has been made? 4-8 may change based on C-ABC Continue the TNP assuming the patient was intubated. 9-11 9**. If intubated, assess endotracheal tube placement 10. If intubated, assess ETT position and securement 11. If intubated, state the need to begin mechanical ventilation or continue assisted ventilation Continue the TNP following assessments of ETT. 12-15 **12, 13, and 15 are double-starred 12**. Assess circulation 13**. Assess neurologic status using GCS 14. Assess pupils 15**. Remove all clothing AND inspect for obvious abnormalities or injuries Continue the TNP following assessments of circulation, neuro status, and removal of clothing to inspect for injury. 16-18 16. Provide warmth 17. Obtain a full set of vital signs and weight in kilograms (if not determined earlier) 18. Facilitate family presence Continue the TNP using the LMNOP mnemonic. 19-23 19. L - trauma panel labs 20. M - monitor (Cardiac, consider EKG) 21. N - consider need for NG/OG 22. O - assess O2 and end-tidal capnography 23**. P - assess pain using appropriate pain scale Continue TNP after LMNOP (so after pain has been assessed). 24-26 24. Non-pharmacological comfort measures 25. Consider analgesic med order 26. Obtain pertinent history Head-to-Toe 27-43 27. Inspect and palpate head for injuries 28. Inspect and palpate face for injuries 29. Inspect and palpate neck for injuries -- Demonstrate removal AND reapplication of cervical collar for assessment (if indicated). 30. Inspect and palpate chest for injuries 31. Auscultate breath sounds 32. Auscultate heart sounds 33. Inspect the abdomen for injuries 34. Auscultate bowel sounds 35. Palpate all four quadrants of the abdomen for injuries 36. Inspect and palpate the flanks for injuries 37. Inspect the pelvis for injuries 38. Apply gentle pressure over iliac crests downward and medially 39. Apply gentle pressure on the symphysis pubis (if iliac crests are stable) 40. Inspect the perineum for injuries 41. Consider GU - urinary output 42. Inspect and palpate all four extremities for neurovascular status and injuries 43. Inspect and palpate posterior surfaces -- NOT if the patient has suspected spinal or pelvic injuries After the head-to-toe, the learner should summarize injuries identified throughout the scenario and ask themselves: "What interventions or diagnostics can you anticipate for this patient?" 1/6 44. Identify at least THREE interventions or diagnostics these may include the following: Antibiotics Consults Head CT for any alterations in mental status Imaging (other radiographs, CT, ultrasound, interventional radiolFollowing the completion of head-to-toe assessment in TNP, you ogy as indicated) must do what? 44 Law enforcement Mandatory reporting Psychosocial support Social services Splinting Tetanus immunization Wound care "What findings will you continue to reevaluate while the patient is After identifying potential interventions/diagnostics and completin your care?" ing your assessments and interventions, you should ask yourself what? "Just keep re-evaluating" Just Keep Reevaluating. 45-48 45. Reevaluate vital signs 46. Reevaluate all identified injuries and effectiveness of interventions 47. Reevaluate primary survey 48. Reevaluate pain What do you ask yourself after re-evaluations are done? 49-50 49. "What is the definitive care for this patient?" 50. Consider need for transfer to a trauma center or admission After all of the assessments, interventions, reassessments, etc. are done, what is the last thing to ask? "Is there anything you would like to add at this time?" When considering GU and how to monitor urinary output: - Assess for contraindications for an indwelling urinary catheter - External catheter - Weighing diapers (pediatrics and adults) Apply gentle pressure over iliac crests downward and medially. If How do you first assess for pelvic instability? Then what do you iliac crests are stable, then apply gentle pressure on the symphdo? ysis pubis. T/F: It is appropriate to consider transfer to a higher level of care before or during the A-E. True. Consider this throughout. What is a systematic process to guide your care of trauma patients? trauma nursing process What does it mean to have double-starred criteria? It means that this criteria MUST be done in order. For double-starred criteria, ___ and ___ must be completed prior to moving to the next step. assessments, interventions Double-starred criteria include letters ___-___. A-E What does it mean to have single-starred criteria? This means the criteria needs to be done, but the sequence is not critical. **A stands for ___ and ___. alertness, airway **B stands for ___ and ___. breathing, ventilation **C stands for ___. circulation **D stands for ___. disability **E stands for ___. exposure What are the 4 potential single-starred criteria? - reassessment of primary survey interventions - blood glucose if alterations in mental status noted in disability assessment - pain assessment using appropriate pain scale - inspection of posterior surfaces (unless CI) 2/6 Why might inspection of posterior surfaces be contraindicated? May be contraindicated by suspected spine or pelvic injury You must assess pain using an ___________. appropriate pain scale What are the double-starred criteria? (hint: A-E) **Alertness and Airway **Breathing and Ventilation **Circulation **Disability **Exposure T/F: Preparation and triage in TNP includes the activation of the trauma team, role assignment, preparation of the trauma room, and donning PPE. True What might you ask yourself during preparation and triage? "Is there any specific equipment that you would prepare?" Trauma room preparations might include: - Bariatric equipment - Difficult airway or IV equipment - Fluid warmer - Pediatric equipment While donning PPE, you should consider 2 things: 1. potential safety threats to the team 2. need for decontamination The general impression in TNP is to... Assess for obvious uncontrolled external hemorrhage or unresponsiveness/apnea and the need to reprioritize to C-ABC. What might need to be reprioritized during the general impression? Why? You may need to switch from ABCs to C-ABCs in the case of uncontrolled external hemorrhage. During the general impression in TNP, when alterations are idenIntervene as appropriate and continuously reassess for efficacy tified, you must do what? Then what? What interventions are potentially included in the general impression? - pulse - control of external hemorrhage - initiation of chest compressions - initiation of IV resuscitation Why would you initiate IV resuscitation? for signs of significant blood loss with signs of very poor perfusion T/F: During the general impression, you can perform the assessment and interventions simultaneously when multiple team members are present. True. T/F: During the general impression, assessments and interventions identify life-threatening conditions, and you should prioritize the life-saving interventions. Order of step completion is not important. False. Order of step completion is of critical importance. What is the first double-starred assessment? What step is it? Alertness and AVPU are the first double-starred assessments. It is step 5**. What should you ask yourself when assessing for alertness, avpu? Is the patient Alert, do they require a Verbal or Painful stimulus to respond, or are they Unresponsive? True T/F: If the patient was deemed unresponsive in step 4, you do not General impression is step 4, and if you already know the patient need to assess level of alertness, avpu. is unresponsive, they won't be alert or responsive. What 2 things must you do when opening the airway if c-spine injury is suspected? 1. You need to have a second person provide manual cervical spinal stabilization 2. You must demonstrate manual opening of the airway using the jaw-thrust maneuver When assessing for alertness and airway, you must simultaneously ___________. continue cervical spinal stabilization T/F: Even if the patient is alert and can cooperate, you must demonstrate manual opening of the airway using the jaw-thrust maneuver. False. When the patient is alert and can cooperate, it is acceptable to ask the patient to open their mouth to assess the airway. 3/6 Acceptable things to ask about during this step include assessments for: - Bony deformity - Burns - Edema Give at least 4 examples of things to inquire about when assessing - Fluids (blood, vomit, or secretions) the patency and protection of the airway: - Foreign objects - Inhalation injury (burns, soot) - Loose or missing teeth - Sounds (snoring, gurgling, or stridor) - Tongue obstruction - Vocalization When alterations are identified during the assessment of airway patency and protection, you must ___ as appropriate and remember to ___. intervene, reassess What are some interventions that may be appropriate when alterations in airway patency and protection are noted? - Anticipate the need for intubation - Insert an oral or nasopharyngeal airway - Remove any loose teeth or foreign objects - Suction the airway Give at least 4 examples of things to inquire about when assessing breathing efficacy: - Breath sounds - Depth, pattern, and general rate of respirations - Increased work of breathing - Open wounds or deformities - Skin color - Spontaneous breathing - Subcutaneous emphysema - Symmetrical chest rise and fall - Tracheal deviation or jugular venous distention What are some interventions that may be appropriate when alterations in breathing efficacy are noted? - Anticipate need for a chest tube - Anticipate need for drug-assisted intubation - Anticipate need for decompression of pneumothorax - Anticipate need for oxygen - Provide bag-mask ventilations What 3 things must be done if the patient is intubated? - Attach a CO2 detector device. After 5 to 6 breaths, assesses for evidence of exhaled CO2. (EtCO2) - Simultaneously observe for rise and fall of the chest with assisted ventilations - Auscultate over the epigastrium for gurgling AND lungs for bilateral breath sounds After how many breaths do you assess for the evidence of exhaled CO2? After 5 to 6 breaths. If intubated, you must assess which 2 things? 1. Assess ETT position by noting the number at the teeth or gums 2. Assess how the ETT is secured How do you assess ETT position? by noting the number at the teeth or gums What are some ways an ETT may be secured? Screw clamp: Secures the ETT to the holder without blocking the tube Hook-and-loop strap system: Secures the ETT to the holder without blocking the tube Cloth tape: Knotted around the ETT and patient's neck Commercial ETT holders: Secure the ETT If a patient is intubated, you must state... the need to begin mechanical ventilation or continue assisted ventilation What 2 elements must be identified when assessing circulation? - Inspect AND palpate the skin for color, temperature, and moisture - Palpate a pulse 4/6 - Anticipate goal-directed therapy for shock - Apply a cardiac monitor - credit given in Step 20 - Apply a pelvic binder - Apply a traction splint - Assess patency of prehospital IV lines - Compare central and peripheral pulses - Consider sources of internal hemorrhage What are some interventions that may be appropriate when alter- Control external hemorrhage ations in circulation are noted? - Draw labs - credit given in Step 19 - Facilitate FAST and/or radiographs to identify source of internal hemorrhage - Initiate chest compressions and advanced life support - Obtain IV or IO access (two sites) - Palpate central pulse if peripheral pulse is absent - Tilt pregnant patient or manually displace the uterus T/F: It is acceptable to have one IV or IO site on a patient with altered circulatory status. False. You must have two sites of access. What is assessed in GCS? Best eye opening (1-4) Best verbal response (1-5) Best motor response (1-6) What are some interventions that may be appropriate when alterations in neurological status are noted with GCS? - Anticipate the need for a head CT - Anticipate the need for drug-assisted intubation - Assess bedside glucose (*with altered mental status) You should determine neurological status using GCS ___ (before / after) sedation and intubation. before T/F: The GCS is documented as non-testable if there is a factor, such as sedation or paralytics, interfering with communication. True. This is why you should determine neurological status prior to administering medication for intubation if possible. When you remove all clothing, you are also doing what? you're also inspecting for obvious abnormalities or injuries T/F: When newly identified life-threatening alterations are identified, intervene as appropriate and reassess. True. Always intervene and reassess. T/F: Delay removal of transport device when possible. False. If a transport device is in place, it may be removed as soon as possible. If there are no contraindications, the patient may be turned to quickly assess the ___. posterior This is deferred until after the head-to-toe and imaging if needed to evaluate spinal and pelvic stability. - Blankets - Increase room temperature - Warmed fluids - Warming lights You must provide warmth by identifying at least one of the following: Labs May include but not limited to the following: Blood gases Blood cross/type and screen Coagulation studies Complete blood count Lactate Metabolic panel Pregnancy Toxicology screen L in LMNOP M in LMNOP monitor cardiac status and consider EKG - also set BP to recycle as indicated O in LMNOP oxygen and EtCO2 P in LMNOP assess pain 5/6 - Increase or decrease rate of assisted ventilation - Wean oxygen (consider parameters other than oximetry due to hypothermia, vasoconstriction, and skin color's impact on pulse oximetry measurements) If alterations in oxygenation or EtCO2 are noted, interventions may include but are not limited to the following: When is capnography highly recommended? When is capnogra- recommended for all patients, vital for sedated or ventilated paphy vital? tients You must identify at least one of the following non-pharmacological comfort measures: - Distraction - Family presence - Places padding over bony prominences - Repositioning - Splinting - Verbal reassurance What should be considered when applying ice to patients for comfort? Applying ice to swollen areas may be appropriate but consider hypothermia risk for major trauma and very small pediatric patients. What should be considered when providing warmth? Warmth may be appropriate, but consider burn risk. Identify at least one of the following when obtaining pertinent history: - Medical records/documents - Prehospital report - SAMPLE 6/6